Suffering Adds Up in a Hurry
14 January 2005 For two days this week, an Australian doctor and his Acehnese assistant knocked on every 10th door in Calang, a seaside town on Sumatra island that was decimated by the Dec. 26 tsunami. At each house, they asked the same brief questions, thanked the residents and departed after about 10 minutes. What they learned in their bare-bones, random statistical survey, conducted for the International Rescue Committee, was chilling. Before the tsunami, 8,700 people lived in Calang; now, that number is 2,500, and a third of those are displaced from other towns. Sixty-five percent of households have had a death in the immediate family. Twenty-two percent have taken in orphans, usually more than one. Only 8 percent of the population is younger than 5, and 85 percent of those children have had diarrhea in the past two weeks. The survey, conducted by Richard Brennan and his assistant, Kamaruddin, has provided the most precise look to date at the tsunami's effects on the people living in the worst-hit part of the worst-hit country. The survey produced more than numbers, however. It will help the International Rescue Committee, a humanitarian relief agency based in New York, plan how best to spend the $7 million it has budgeted to assist Indonesian survivors of the tsunami. Relief organizations often use such systematic assessments during man-made disasters involving war, famine and forced dislocation, in which people's needs may not be obvious. In natural disasters, relief experts said, the aid requirements are usually more clear-cut because the disruption tends to be short-lived and the sufferers start off healthy. But in the case of the recent tsunami, the magnitude of damage in Indonesia indicates that its effects will be severe and long-lasting. Brennan's survey of Calang's households began Monday on one side of the tiny peninsula on the west coast of Sumatra. Two Indonesian navy ships were moored offshore. The flat land beyond the beach where the tsunami came ashore was covered with fallen palm trees and trash. There were a dozen green military tents, and an orange one containing an Indonesian Red Cross clinic. A steady stream of refugees came and went, with people picking up boxes of flavored noodles and sorting through sodden piles of donated clothes. The day before, Brennan had canvassed the residential area, built on slopes that drop toward the sea, and decided he needed to visit one in 10 homes to compile enough data to make the results of the survey valid. To make it truly random, however, his starting point couldn't be the first house he encountered, but rather a point that could not be predicted. So his first scientific move in Calang was to ask someone for some paper money and then to read off the last digit in its serial number, which was a 2. The scientific approach to disaster relief can be controversial. Some critics think it is foolish to prove the existence of "obvious" needs and cruel to ask for information before giving help. Brennan, 45, who heads the International Rescue Committee's health activities program, is not one of them. "Okay," he said, "we start counting after the second house." This meant that the third house near the beach became Household No. 1, the first to be surveyed. It was a one-room shack built from scavenged wood, corrugated metal sheets and dried palm branches. Brennan approached a woman squatting inside who was surrounded by children. His first question was: "Where are you from?" The second was: "How long have you been here?" Then: "How many people slept here last night?" The interpreter, whose only name is Kamaruddin and who uses the nickname Odon, took down the answers. At the third question, the woman seemed confused, and then Odon became engaged in an extended conversation with a man outside the shelter. "Odon, don't get distracted, please," said Brennan, who hoped to complete the survey that day so he could move onto outlying villages. "She can't count," the interpreter replied. It turned out the answer was 13 -- one of the larger households the team would encounter. Brennan still needed the age and sex of each person. And he had a dozen more questions after that. When the encounter was finally over, the visitors descended into a wide gully that had been made by the retreating water. It was full of tangled fronds, branches and uprooted trees. On the other side rose the hill where the next group of houses stood. Odon stopped in the middle of the gully. "Rick, I think we need to ask fewer questions," he said. "They don't like just to give information and get nothing. If you go to someone's house three times and give them nothing, they will get angry." Brennan said he was acutely conscious of the problem. He told Odon he had used a satellite telephone that morning to try to reach the International Rescue Committee's emergency coordinator in Banda Aceh and request that a water and sanitation engineer be sent to Calang. Even without an assessment, he said, it was clear that people needed clean water and latrines. Unfortunately, he couldn't reach her. "So what have you done?" demanded Odon, 29. Brennan said he had divided a large box of medicine and bandages between the Indonesian Red Cross clinic and a German clinic and promised that his office would send the engineer as soon as it could. "Is that convincing?" Brennan asked with a doubtful smile. "I need to convince you before you can convince them." But nobody in Calang refused to talk to the surveyors. Everyone was gracious. Two people asked for cigarettes, and two asked for rice. The team had only thanks to offer, though at some stops they let children peep at a digital photograph of themselves. Up and down the hillsides the team went, stopping at every 10th house. If no one was home, they moved to the next house. They defined each "household" as a group of people who ate from one pot; some large structures contained more than one. Each dwelling was a testament to human resourcefulness. The humblest was a lean-to where five people appeared to sleep on the ground, except for an infant in a hammock. The most elaborate was a wood-frame house with rafters made of galvanized pipe, with woven mats covering the floors. With rain almost constant, the settlement was a cat's cradle of lines hung with drying clothes. Brennan's survey included questions about where each household obtained water and how much it used each day. The team inspected and estimated the capacity of buckets, jerrycans and former chemical containers used for storing water. The visitors also made one measurement of each young child they encountered. The "mid-upper-arm circumference," known to epidemiologists as MUAC, changes little in children between 6 months and 5 years of age and is used as way of screening for malnutrition. Odon, although not completely convinced of the survey's usefulness, assisted willingly. He kept the multicolored MUAC tape around his shoulder bag, and he and Brennan exchanged jokes about the adventures of "Mr. MUAC." Over the course of two days, a solid statistical portrait emerged of the tsunami's effects on Calang. There were 316 households, with an average size of 7.6 people. Most had lost at least one member, but the precise mortality rate remained unknown because some families had been wiped out and some survivors had left. Children and the elderly seemed to have died at a slightly higher rate than adults -- although the town was filled with orphans. Nationwide, children younger than 5 constituted 10 percent of Indonesia's population in 2003; in Calang, the number is 8.2 percent. People older than 60 made up 7.9 percent of the nation's population before the tsunami; in Calang, the figure is 4.5 percent. The oldest survivor in the area was a woman of 80; a woman in the same household who was over 100 had died. Yet considering the enormity of the disaster, the survivors of Calang seemed to be in generally good condition. The orphans were all being cared for, and there were no cases of acute malnutrition. Almost everyone defecated outdoors, nobody was drinking from a "protected" water source, and childhood diarrhea -- spread by fecal contamination of food and water -- was common. Yet no cases suggested cholera or dysentery. Sick people were seeing doctors, and most reported being happy with the treatment they received. Brennan, who planned to share his findings with the World Health Organization's office in Banda Aceh, said the survey convinced him that the International Rescue Committee had made the right decision to concentrate on improving water quality and building latrines in Calang and to deploy its medical resources elsewhere. In one house, the surveyors met a 32-year-old carpenter they had seen earlier at the Indonesian Red Cross clinic, where he had brought his infant daughter. The baby had a large, tender swelling below her jaw. Brennan and another doctor had concluded that it might be an infection of a salivary gland, and they prescribed an antibiotic. When Odon reached the survey question about whether people were satisfied with medical treatment they had received in the last week, Brennan grinned at the carpenter and warned, "Careful what you say, mate." The man replied, "It's hard to say. We'll have to see how the baby does when she takes more medicine." Brennan rejoined: "Good answer."
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